How to Manage Orthostatic Hypotension Related to Psychiatric Medication

Orthostatic hypotension is a common adverse event associated with psychiatric medication; about 6% of community-dwelling older patients can experience orthostatic hypotension. During a presentation given by Rajnish Mago, MD, clinical assistant professor in the Department of Psychiatry at the University of Pennsylvania, at the Neuroscience Education Institute Max! Virtual Meeting, he described effective strategies for assessing and managing orthostatic hypotension in patients taking psychiatric medication.

Dizziness has to be distinguished between faintness and lightheadedness or vertigo. When the person feels faint, it’s likely to be orthostatic hypotension, according to Dr. Mago. Certain medications are associated with orthostatic hypotension, including those that block alpha-1, antipsychotics, and intramuscular antipsychotics; antidepressants and benzodiazepines can also reduce vascular tone. In addition to medications, other illnesses can lead to this such as cardiovascular disease, cerebrovascular disease, diabetic neuropathy, and Parkinson’s disease. Low blood pressure and dehydration are other risk factors.

Dr. Mago advised asking patients if they have dizziness, pressure or dull pain in the back of their neck, visual disturbances, and palpitations, as well as asking about when it is worse — in the morning, after taking medications, after meals, etc.

“One of the simplest ways to assess orthostatic hypotension is to have the person stand up rapidly and see if they felt anything. If it reproduces the symptom, that confirms it,” he said. Assess patients’ blood pressure and pulse after they are sitting or laying down for five minutes, after standing for one minute, and after standing for three minutes. Orthostatic hypotension can be determined when there is a drop in systolic blood pressure of >20 mmHg or a drop in diastolic blood pressure of >10 mmHg.

“First, we should think about level 1 interventions,” he said. Consider both psychiatric and non-psychiatric medications and change them, if possible. In addition, minimize the peak levels of medications — put them on a sustained-release preparation or give them in split doses. Patients should be advised to avoid hot baths and showers, alcohol, and Valsalva maneuvers (e.g., straining when going to the bathroom or picking up something heavy).

Dr. Mago said a trick for patients is to drink 16 oz. cold water 30 minutes before getting up. Patient should get up slowly and in stages and should be advised to exercise, particularly swimming or riding a recombinant bike.

Level 2 treatment considerations include abdominal binders and compression stockings to provide mild and adjustable compression. “The abdominal binder is the best thing you can do other than prescribe a medication,” he said. Patients should also increase their salt intake through food or through sodium chlorine tablets if they have low blood pressure. If they have high blood pressure or heart failure or renal failure, do not increase salt intake. Patients should be monitored for fluid retention.

Level 3 treatment considerations are pharmacological: fludrocortisone (mineralocorticoid) is first-line treatment if patients do not have hypertension or heart failure. Midodrine (selective alpha-1 agonist), droxidopa (norepinephrine precursor), and pyridostigmine (cholinesterase inhibitor) are other options.

Presentation: Grandma Might Fall! Identifying and Managing Orthostatic Hypotension Due to Psychiatric Medication. Presented at the Neuroscience Education Institute Max! Virtual Meeting, Nov. 5-8, 2020.